Draft pending legal review. This document was prepared from official federal and California state templates and has not yet been reviewed by an attorney. Highlighted passages still need to be completed before publication. It is published here so the page structure and links can be finalised - please have counsel review the wording before relying on it.
Effective Date: [insert date this is actually published]
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Commitment to Your Privacy
We understand that information about you and your health is personal. We are committed to protecting information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by us.
This notice will describe your rights and certain responsibilities we have regarding the use and disclosure of your health information. This notice will also tell you about the ways we may use and disclose information about you.
Your Rights
You have the right to:
- Get a copy of your health and claims records - you can ask to see or get a copy of your health information. We will provide a copy or summary of your information, usually within 30 days of your request.
- Ask us to correct your health and claims records - you can ask us to correct information you believe is incorrect or incomplete. We may say no, but we will explain why in writing within 60 days.
- Request confidential communications - you can ask us to contact you in a specific way (for example, home or office phone) or send mail to a different address, and we will agree to all reasonable requests.
- Ask us to limit what we use or share - you can ask us not to use or share certain health information. We are not required to agree, except in specific circumstances required by law.
- Get a list of those with whom we've shared information - you can ask for a list of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- Get a copy of this privacy notice - you can ask for a paper copy of this notice at any time, even if you agreed to receive it electronically.
- Choose someone to act for you - if someone has medical power of attorney or is your legal guardian, that person can exercise your rights and make choices about your health information.
- File a complaint if you feel your rights are violated - you can complain by contacting us using the information below, or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by mail (200 Independence Avenue, S.W., Washington, D.C. 20201), phone (1-877-696-6775), or online (hhs.gov/hipaa/filing-a-complaint). We will not retaliate against you for filing a complaint.
How We Typically Use or Share Your Health Information
We typically use or share your health information in the following ways:
- To treat you - we can use your health information and share it with other professionals treating you, such as coordinating your prescriptions with your prescribing doctor.
- To run our organization - we can use and share your health information to run our pharmacy, improve your care, and contact you about services and offerings that may be of interest to you.
- To bill for services - we can use and share your health information to bill and receive payment from health plans or other entities.
How We May Share Your Health Information for Other Reasons
- To help with public health and safety issues, as required by law
- For health oversight activities, such as audits or investigations
- In response to a court or administrative order, or a subpoena
- With law enforcement, when required by law
- To coroners, medical examiners, or funeral directors
- To organ procurement organizations
- For research purposes, under specific legal protections
- To avert a serious threat to health or safety
- For special government functions, such as military or national security purposes
- For workers' compensation claims
[If applicable - attorney to confirm]: We will not share information from your substance use disorder treatment records (if any) except as specifically permitted under 42 CFR Part 2, which provides additional federal protections beyond standard HIPAA rules.
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time by informing us in writing.
For more information, see hhs.gov/hipaa/for-professionals/privacy/index.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
Contact Us
Privacy Officer: [insert name/title]
Phone: (818) 572-9982
Email: [insert privacy-specific contact email if different from general inquiry email]
Address: 500 N. Brand Blvd, Glendale, CA 91203